Q&A: Dismantling Stigma in Modern HIV Care and Prevention

Despite monumental advancements in biomedical interventions, the landscape of HIV care and prevention remains shadowed by persistent stigmas that impede public health progress. Modern misconceptions often target highly effective tools like pre-exposure prophylaxis (PrEP), with critics inaccurately suggesting that these prevention methods drive spikes in other sexually transmitted infections (STIs) due to decreased condom use, according to Kenric B. Ware, PharmD, MBA, AAHIVP, clinical associate professor of pharmacy practice at Mercer University.

In reality, the perceived rise in STIs is often a byproduct of more rigorous and frequent testing protocols integrated into PrEP maintenance. Furthermore, many still harbor the outdated belief that any person living with HIV is a vector for transmission, ignoring the fact that modern antiretroviral therapy can reduce viral loads to levels that pose zero risk to partners.

The persistence of these stigmas in an era of diversity and inclusion is largely fueled by misinformation and the siloing of HIV discourse within specialized medical communities. When conversations regarding treatment and prevention are restricted to infectious disease experts, the broader public—and even primary care providers—may remain "naïve" to the realities of the virus, inadvertently perpetuating "othering" behaviors.

To normalize HIV care, the health care sector must shift toward integrating treatment into primary care settings and prioritizing inclusive representation in media campaigns. By ensuring that diverse populations see themselves reflected in health care outreach and by dismantling the barriers between specialized and general medicine, the industry can transition HIV from a stigmatized isolation to a manageable, normalized component of routine health maintenance.

Drug Topics: What are the common stigmas surrounding HIV care and prevention today?

Kenric B. Ware, PharmD, MBA, AAHIVP: So a common stigma around HIV care is that HIV pre-exposure prophylaxis, so we refer to it as PrEP for short. It's really made up of biomedical interventions that are either oral or injectable. One stigma is that PrEP is leading to higher rates of sexually transmitted infections such as gonorrhea, chlamydia, and syphilis. The premise is that since people may be less concerned about acquiring HIV because they are taking PrEP, then they are less likely to use condoms, and STIs may spike in return.

However, this data really [doesn’t] bear this out. In reality, what happens is we’re checking for testing transmitted infections more during reassessments for PrEP, so when people have to reassess to make sure they're not living with HIV, they're still a candidate for prevention. We're picking up more of those STIs, but that's a really big stigma point where towards PrEP in that, in and of itself, people believe that it's leading to increases in STIs, which really it is not.

Another stigma that exists is the notion that anyone living with HIV can transmit HIV to other people. Well, in reality, that's not true either. We have what's called “undetectable equals untransmittable,” and in essence, what that refers to is we've advanced so far into the medical therapies now is that we can actually manage people's HIV to where the virus is so low in the body that it effectively poses no risk to transmit to other people. In essence, all HIV wouldn't be created equal, because we're going to have different viral loads. The goal of drug therapy, one of the goals, is to lower that viral load as low as possible so that people don't transmit it to others. So that's another stigma, that HIV is kind of a one-size-fits-all model when it's not.

Drug Topics: With many societal developments leaning toward diversity and inclusion, how have HIV-related stigmas persisted in today’s health care landscape?

Ware: You would think that they wouldn't because we've made so many strides. I think that one of the main culprits is just misinformation. People just not being adequately informed about how effective the HIV prevention and treatment options are, and candidly, I really do believe that a lot of the HIV conversations tend to still kind of be happening in isolation. We're kind of insulated sometimes in the HIV community. What I mean by that is people who work within the HIV care continuum have a tendency to talk to each other a bit more about these HIV-related conditions, as opposed to at conferences and meetings, as opposed to talking to people maybe outside of that community more. Hence, that stigma can persist due to exclusion, albeit it's not intentional, but I do think some of the stigma is because we're not necessarily as inviting to people who are “naïve” to the HIV space.

Drug Topics: What are the best approaches to addressing HIV stigmas and making care and prevention a normal process in the health care sector?

Ware: I think one notable way is incorporating more HIV treatment and prevention into kind of primary care arenas, as opposed to restricting them to infectious disease specialties, which obviously will help normalize this whole HIV consideration within the health care sector. Obviously, this would necessitate that primary care providers become more comfortable with HIV care delivery and not simply referring to the infectious disease experts, because we want to make sure that they don't inadvertently perpetuate stigmas themselves from not being as comfortable.

I think also additionally ensuring that HIV prevention and treatment modalities are portrayed in the media and through commercials in the best way they can right to make sure that whatever is being portrayed through commercials or through social media, that there is representative and inclusive as possible, right? So that goes a long way from to normalizing it so people can see themselves reflected in these in these advertisements. We talk a lot about in this space how representation matters, and so if you're looking at commercials, or if you're scrolling on social media, and you don't see yourself reflected in some of these campaigns, then you may begin to other it, right? And say, “Well, those are for other people and not me.”